State of the Healthcare API Economy

Rasu B. Shrestha, Chief Strategy Officer, Atrium Health

Santosh Mohan, Member, HIMSS Innovation Committee

Grahame Grieve, FHIR Product Director, HL7 International

An Innovation Forum Session Session 217, February 14, 2019

Today’s Speakers

Santosh Mohan, MMCi FHIMSS

Member

HIMSS Innovation Committee

Twitter: @santoshSmohan

Rasu B. Shrestha, MD MBA

Chief Strategy Officer

Atrium Health

Chair: HIMSS Innovation Committee

Twitter: @RasuShrestha

Grahame Grieve

FHIR Product Director

HL7 International

Twitter: @GrahameGrieve

Grahame Grieve

Has no real or apparent conflicts of interest to report.

Rasu B. Shrestha, MD, MBA

Has no real or apparent conflicts of interest to report.

Santosh Mohan, MMCi, CPHIMS, FHIMSS

Has no real or apparent conflicts of interest to report.

Conflict of Interest

• Discuss the value of open APIs and networks and review the

opportunities and challenges represented by them

• Explore need to build future API touch-points that can allow tighter

workflow integration and a more open ecosystem of applications

• Identify sustainable approaches and examine a maturity model

with essential, nice to have, and future need capabilities to nurture

and scale API-led innovation

• Describe critical issues facing health innovation developers and

identify ways to foster a thriving ecosystem of partners

Learning Objectives

Epic Systems

Verona, WI

Health Level Seven International

Ann Arbor, MI

Jefferson Health

Philadelphia, PA

Redox

Madison, WI

Rush University Medical Center

Chicago, IL

The Health Care Blog

San Rafael, CA

Matthew Holt

Founder & Publisher

Trinity Health

Livonia, MI

VCU Health

Richmond, VA

Xealth

Seattle, WA

Allscripts

Chicago, IL

The Argonaut Project Community

athenahealth

Watertown, MA

Michael Palantoni

Executive Director, Platform Strategy and Operations

Hunter Johnstone

Associate, Platform Strategy and Operations

CareJourney

Arlington, VA

Cerner Corporation

Kansas City, MO

Chilmark Research

Boston, MA

Brian Murphy

Industry Analyst

Cleveland Clinic

Cleveland, OH

Acknowledgements

APIs are the future

of healthcare.

Application Programming Interface

business models

business channels

secure access

exchange of data

API Economy

Our world has changed.

The world

has changed.

Healthcare

deserves better.

1980

APIs are the latest in a long road to healthcare interoperability

1990

2000

2010

HL7 v1 (1987) and HL7 v2 (1988)

• Messaging formats containing patient information and designed for machine processing

• Flexible and varies by use case, e.g. SIU (scheduling), ADT (Admit/Discharge/Transfer)

HL7 CDA (2005)

• Document standard for HL7 v3 designed to output patient encounter data in a “user-readable”

format (has both XML and HTML components)

• Flexibility spawned many sub standards (e.g. the C32 constraint for Meaningful Use Stage 1)

2004: Office of the National

Coordinator (ONC) created

2009: HITECH Act passed

2010: MU Stage 1 2012: MU Stage 2

1987: First meeting of HL7

2018: MU Stage 3

mandatory for all providers

HL7 FHIR (2011+)

• Defines “resources” (e.g. allergy info) and APIs to access them

• Resources can be bundled into documents/messages

• Logically compatible with HL7 v2 and C-CDAs

• Enables app integration using SMART on FHIR standard

2020

API Standards: robust information

exchange for many purposes

Build on Web technology,

security, communities

Messaging: specific

interfaces for closed

functionality

Documents: general

purpose format for

everything

APIs drive costs down

Stable / robust information handling techniques

Wide availability of developers, Libraries

Deep debugging / testing frameworks

Re-use existing security approaches and arrangements

Proven solid methods of developing communities

But… Health is still hard!

Entrenchment has historically required time, critical mass, and gov’t

involvement

2012: MU2 proposal requires solely C-CDA for summary of care records

2010: MU1 includes CDA formats among those allowable for clinical care summaries

2011: ONC, HL7 create the C-CDA as single standard for care summaries

2014: MU2 reporting period begins; criticism mounts on C-CDA inconsistency; first FHIR version released

2012-2014: athenahealth, Epic, other EHRs adopt C-CDAs to meet MU2

1997: Physician group drafts CDA standard

2000: HL7 publishes CDA Release 1

New Adoption

/ Mindshare

Time

C-CDA

2005: HL7 publishes CDA normative release

Entrenchment has historically required time, critical mass, and gov’t

involvement

2018 Q1: MU3 requires availability of clinical data via open APIs; Apple Health integrations go live

2015: FHIR DTSU 2 published; EHRs show support with FHIR dev tools at

HIMSS

2017: FHIR DTSU 3 published with 30+ core endpoints mature enough for

use

2016: Major consumer brands rally around FHIR through CARIN Alliance

2011: First proposal for FHIR standard

2014: HL7 publishes FHIR DSTU 1 (Q3); Argonaut Project begins

(Q4)

New Adoption

/ Mindshare

Time

FHIR

Present

13%

45%

34%

Total Responses: 54

How available would you say the

FHIR standard is these days?

Available for Read, Write, Update

Available for Read

Not Widely Available

Not Sure

Source: Holt, M., Dunn, O. And Krueger, K. (2018). EMRs, APIs, App Stores & All That: More data | THCB. [Online] thehealthcareblog.Com. Available

at: http://thehealthcareblog.Com/blog/2018/11/28/emrs-apis-app-stores-all-that-more-data/ [accessed 8 feb. 2019].

FHIR Goals were always economic

• Interoperability is about economics (cost shifting)

• Develop a general purpose healthcare API standard

• Use PHR as an exemplar for economic impact

○ TCO for Personal Health Repository: $150k is not a

sustainable cost

○ Develop PHR specification (Argonaut)

○ Goal: 90% reduction in TCO - probably achieved

Applications of open APIs and FHIR

Personal Health Managers

• Apps that pull in clinical data from EHRs, health apps, and medical devices/wearables (e.g. Apple

Health)

Data Analytics & Reporting

• Granular access to clinical data across EHRs (e.g. for pop. health, payers)

• Easily building Clinical Data Repositories

Health Care Process Improvements

• Integration of new workflows between provider and payor

• Seamless transitions of care on an ongoing basis

FHIR Based Applications

• Build entire applications from scratch using FHIR as internal API

Application Extensibility

• Patient- or provider-facing apps that access clinical data to/from an EHRs & provide new services

Positives

• Access to relevant, granular data vs. large, redundant flat files

• Mobile-friendly

• Standard access to data elements across EHRs

• Uses familiar web standards (XML, JSON, HTTP, SSL, OAuth 2.0)

• Internal standardization for multiple products/workflows

• Backwards compatible (e.g. FHIR resources can be compiled into C-CDAs)

• Open source libraries (e.g. HAPI-FHIR, SMART on FHIR)

Negatives

• Standardization is not yet complete

• FHIR adoption still low and standard not fully mature

FHIR has all the characteristics of a next-

generation standard

Sample C-CDA: Summary of Care

931 lines

Sample FHIR Resource:

Medication Order

63 lines

Limits of FHIR

• The dream: fully

standardized content

○ Requires consistent

configuration, work

practices

○ ~100,000k care providers,

no(?) interest in

standards

• HL7 standardizes

exchanges

○ ~1000 vendors

understand how

standards work

○ Highly configurable

systems - limit what can

be standardized

CDS Hooks aims to give external services

a way to plug into the EHR

Consumer-driven exchange may expedite

adoption of a shared standard

Mobile health apps that send data to EHRs/clinical research, such as Apple Health and Sync for Science

• Apple Health uses FHIR to import clinical data from EHRs of

select providers

• iBlueButton uses Direct on FHIR to access health data

through government payers

• WebMD Health Manager (and related apps) access a

patient’s clinical data through an employer in C-CDA format

Consumer Access

Consumer Initiated Exchange

Patients EHR

Meds

Problems

Allergies

Clinical Data

Patients EHR

Meds

Problems

Allergies

Clinical Data

Consumers also drive interoperability through:

- Consumer-directed exchange (CDEx) of clinical data between

EHRs at a patient’s request

- Personal health records (PHRs) like Apple Health, Microsoft

HealthVault, and Google Fit aggregate data from fitness, diet, and

disease management apps (and now vying for EHR data as well)

“We share the common quest to unlock the potential in healthcare data, to deliver better outcomes

at lower costs. Open standards, open specifications, and open source tools are essential to

facilitate frictionless data exchange. This requires a variety of technical strategies and ongoing

collaboration for the industry to converge and embrace emerging standards for healthcare data

interoperability, such as HL7 FHIR and the Argonaut Project.”

Source: MANDEL, J. (2018). Microsoft, Amazon, Google, IBM, Oracle, and Salesforce issue joint statement for healthcare interoperability - Microsoft Industry Blogs. [online] Microsoft Industry Blogs.

Available at: https://cloudblogs.microsoft.com/industry-blog/health/2018/08/13/microsoft-amazon-google-and-ibm-issue-joint-statement-for-healthcare-interoperability/ [Accessed 8 Feb. 2019].

Large consumer brands are becoming a driving force behind FHIR

Brand Initiatives

Apple

- FHIR implementation in Apple Health as part of iOS 11.3

- Member of Argonaut Project and CARIN Alliance

Google

- Google Cloud for Healthcare includes Cloud Healthcare API for developers; supports FHIR

- Provides API layers for health system data via Apigee; supports FHIR

- Partnered with HL7 FHIR Foundation and member of CARIN Alliance

Microsoft

- Published HL7 FHIR on Azure guide for implementation of FHIR-based servers

- Ongoing project creating a FHIR library for Microsoft HealthVault mobile app

23andMe

- Subject of proof of concept using FHIR for reading/writing genomics data to/from EHRs

- Member of CARIN Alliance

Verizon

- Member of CARIN Alliance advocating secure PHI transfer using FHIR and OAUTH 2.0

IBM

- IBM Watson Platform for Health supports access and analysis of data via FHIR endpoints

- Member of HL7 Partners in Interoperability & HL7 FHIR Applications Roundtable

So where are we now?

• Proposes nationwide HIE to be managed by a single

Recognized Coordinating Entity (RCE)

– Participation is voluntary

– RCE to be chosen via competitive bidding, must have

history of “multi-stakeholder collaborations and

implementing governing principles”

– RCE will add provisions and technical requirements

(with ONC approval) to cover unaddressed policies

• TEFCA requires qualified entities (i.e. EHRs) to:

– …use a MPI, record locator, and query service

– …be participant neutral (not withhold data)

– …meet standard core data classes

• Recommends use of ISA standards: C-CDA, HL7 v2

messaging, FHIR

• Data Blocking – New rules Proposed this week!

CMS EHR Incentive Program:

Meaningful Use Stage 3 (MU3)

Century Cures Act:

Trusted Exchange Framework (TEFCA)

Source: Monica, K. (2018). APIs, TEFCA Expected to Boost EHR Interoperability Industry-Wide.

[online] EHRIntelligence. Available at: https://ehrintelligence.com/news/apis-tefca-expected-to-boost-

ehr-interoperability-industry-wide [Accessed 8 Feb. 2019].

“Any application chosen by a patient would enable

the patient to gain access to their individual health

information provided that the application is configured to

meet the technical specifications of the API.

Providers may not prohibit patients from using any

application, including third-party applications, which

meet the technical specifications of the API, including

the security requirements of the API.”

– Center for Medicare & Medicaid Services, “Medicaid EHR

Incentive Program Stage 3 - Patient Electronic Access to Health

Information”

Note: For 2019 and beyond, “MU3 – Patient Electronic Access to Health Information”

becomes “Promoting Interoperability Programs – Provider to Patient Exchange”

Seeing the EHR as a platform.

Leading EHRs have all enabled some API integration

(including FHIR)…

• 20+ FHIR resources (DTSU2); proprietary APIs for other use cases

• App integrations available through App Orchard, including SMART on FHIR

• Member of the HL7 Argonaut Project; FHIR integration with Apple Health

• API docs and sandbox publicly available on open.epic: open.epic.com

• 25+ FHIR resources; proprietary APIs for other use cases including pop. health

• All new app integrations through SMART on FHIR (legacy apps may still use proprietary APIs)

• Member of the HL7 Argonaut Project; FHIR integration with Apple Health

• API docs and sandbox publicly available on Cerner | CODE: code.cerner.com

• 15+ FHIR resources (DTSU2); proprietary APIs for other use cases

• App integrations available through Allscripts Developer Program, including SMART on FHIR

• API docs and sandbox publicly available through Allscripts Developer Program: developer.allscripts.com

• 20+ FHIR resources (DTSU2); proprietary APIs for other use cases including pop. health

• App integrations available through MDP, including SMART on FHIR

• Member of the HL7 Argonaut Project; FHIR integration with Apple Health

• API docs and sandbox publicly available on athenahealth Developer Portal: developer.athenahealth.com

34%

48%

17%

24%

67%

85%

11%

46%

42%

12%

In general, the big 4’s APIs are getting better

2018

High technical quality, relatively easy to work with Not great, but workable Poorly designed APIs

Source: Holt, M., Dunn, O. And Krueger, K. (2018). EMRs, APIs, App Stores & All That: More data | THCB. [Online] thehealthcareblog.Com. Available

at: http://thehealthcareblog.Com/blog/2018/11/28/emrs-apis-app-stores-all-that-more-data/ [accessed 8 feb. 2019].

2016

25%

67%

27%

45%

27%

60%

32%

28%

48%

24%

Rise of the app stores of the EHRs

Big 4 becoming much better partners

63%

27%

10%

72%

25%

Program exists; easy to understand Program exists; enrolling somewhat complicated Non-existent programs; difficult to enroll

38%

23%

17%

60%

23%

2018

Source: Holt, M., Dunn, O. And Krueger, K. (2018). EMRs, APIs, App Stores & All That: More data | THCB. [Online] thehealthcareblog.Com. Available

at: http://thehealthcareblog.Com/blog/2018/11/28/emrs-apis-app-stores-all-that-more-data/ [accessed 8 feb. 2019].

2018

App stores enable a nascent ecosystem

for apps using these APIs

117 apps28 apps

225 apps110 apps

Relative availability of apps by use case

Source: Murphy, B. (2018). The Rise of APIs and App Stores In Healthcare. [online] Go.chilmarkresearch.com. Available at:

https://www.chilmarkresearch.com/the-rise-of-apis-and-app-stores-in-healthcare/ [Accessed 8 Feb. 2019].

Relative Availability of Apps in

Hospital Venues

Relative Availability of Apps in

Community Venues

Across care venues, hospitals and

physician offices have the most app

representation

Source: Research, C. (2017). APIs for a Healthcare App Economy. [online] Go.chilmarkresearch.com. Available at: http://go.chilmarkresearch.com/api-

mvsr-2017 [Accessed 8 Feb. 2019].

225+ apps and services

65+ apps in SMART App Gallery

SMART on FHIR:

Application Categories

Source: Gallery.smarthealthit.org. (n.d.). SMART App Gallery. [online] Available at: https://gallery.smarthealthit.org/ [Accessed 8 Feb. 2019].

Benefits of app stores

Cut down integration

costs and

implementation time

Lower investment

and risk

Shopping experience –

choice of similar

functionality within category

Filter signal from noise –

glean from peer reviews

and best practices

Eliminate RFP process Agile pilots – try

before you buy

Hurdles on the track

to substitutable apps

• Thousands of software developers need

more confidence to invest in this technology

• Physicians need to “remember” to launch

an app at the right point during a workflow

• Apps are more focused on read than write

• There is variation in business rules for

connecting apps

• There is variation in API implementations

Source: Mandl, K., Gottlieb, D. and Mandel, J. (2017). ITdotHealth SMART Decisions. [ebook] Smart Health IT. Available at:

https://smarthealthit.org/wp-content/uploads/SMART-ITdotHealth2017-Executive-Summaries.pdf [Accessed 8 Feb. 2019].

72%

83%

39%

40%

14%

21%

29%

14%

10%

25%

26%

14%

Accessed Vendor API Used 3rd Party Integration Engine

Used Batch or Non-API Data Exchange Used Direct or Other Protocol

Use of 3

party integrators growing

Data access method, the big 4 compared in 2018

Source: Holt, M., Dunn, O. And Krueger, K. (2018). EMRs, APIs, App Stores & All That: More data | THCB. [Online] thehealthcareblog.Com. Available

at: http://thehealthcareblog.Com/blog/2018/11/28/emrs-apis-app-stores-all-that-more-data/ [accessed 8 feb. 2019].

Rise of the “API Connectors”

Providers and the

API economy

OUR ROOTS DATE

BACK TO A HUMBLE

BEGINNING.

In 1940, we opened

our doors as Charlotte

Memorial Hospital.

Over the years,

our mission to care for all

has remained the same.

But our reach, our scope

and even our name

have changed.

Atrium Health

• Headquartered in Charlotte, North Carolina

• 50+ hospitals in North Carolina, South Carolina

and Georgia

• 8 Nationally Ranked Clinical Programs

• 3,000+ physicians

• 16,000+ nurses

• 65,000+ teammates

• 7

largest Medical Group in the U.S.

• 12 million patient interactions each year

• $2.03 billion each year in uncompensated care

and other community benefits

A PLACE FILLED WITH LIGHT.

WHERE EACH AND EVERY HEARTBEAT BEGINS.

WHERE CONNECTIONS ARE MADE –

BRINGING HEALTH, HOPE AND HEALING FOR ALL.

A TRI UM:

Are providers a barrier?

Providers may be the biggest hurdle

Do you, as a startup, have:

Total respondents: 54

13% 22% 33% 32%

provider clients

/ prospects

who have

already made

data available

via FHIR?

provider clients /

prospects who are

telling you they will

take part?

little interest in this?

no experience with this?

Source: Holt, M., Dunn, O. And Krueger, K. (2018). EMRs, APIs, App Stores & All That: More data | THCB. [Online] thehealthcareblog.Com. Available

at: http://thehealthcareblog.Com/blog/2018/11/28/emrs-apis-app-stores-all-that-more-data/ [accessed 8 feb. 2019].

Do you, as a startup, find your

provider clients have:

Modern software development and deployment ideas are knocking

on HCO doors

• Cloud deployment, agile development, social/mobile, microservices, REST/JSON,

NoSQL databases have changed IT

• APIs are revenue source for many companies in many industries

New models of care need:

• Broader distribution of clinical expertise

• Delivery in lower cost venues and in different channels

Opportunities to reduce inefficiencies

• Reusable clinical alerts, quality metrics

• New approaches to care coordination

Why should providers do this?

As providers, payers, and patients react to these forces, data

and analytics become a daily need of most medical practices

Regulatory and Contract Performance

Unsustainable Cost

Curve

Consolidation

Patient

Held Risk

Shift from inpatient

to outpatient

Operational efficiency

Schedule Yield

Care Delegation

Patient Engagement

Administrative Efficiency

Network Performance

Referral and Flow Performance

Acquisition and Retention

Clinical Outcomes

Care Pathway Selection and Adherence

Continuity and Coordination

Wellness and Screening

Value and Risk

Consumerism

Operating Efficiency

Trends Responses to Trend Capabilities Required by Responses

Disruptors are focused on using data and analytics as a

key advantage as they respond to these trends

Provider Services Payer Services

Risk

bearing

Non

-risk

bearing

Platform First

Organizations

Disruptive Care Delivery Organizations

Respond

with agility

to market

demands

Be flexible

in vendor

choice

Foster a

culture of

innovation

Give up

some of

your Legos

Open data models will help you to…

Source: Bryson, C. and Olschesky, M. (2018). What Health Systems Can

Gain from FHIR Adoption. [online] datica.com. Available at: https://datica.com/guide/fhir-for-health-systems/ [Accessed 8 Feb. 2019].

Are you actively utilizing/working

on utilizing APIs in any of your

applications?

• We have several in the works,

including integration with

Amazon's Alexa.

• Apple Health, Video Visit

• Apps, claims , health insurance

• Apple Health / Visual Dx / a

Cerner developed one for heart

risk

• Find a Doc, JeffDocs,

myJeffHealth, and more internal

apps. Epic, ECW, AllScripts,

Cerner, etc. as external apps.

• all epic related. IoT

• Medical Year in Review

What are your pioneer

API-based applications?

Is the demand and usage of

API-based apps being driven

mainly by patients or clinicians?

Drivers

Patients Clinicians Both

For any work you’re doing on APIs,

is this:

Who is paying for apps and what

cost considerations (if any) are

driving your efforts?

Which of your existing data

sources will be most valuable for

API-driven applications?

What role does your IT department play with

API-based applications? What are some essential

skill sets and processes to build into the IT

department?

Do you have specific governance

around APIs? Please explain

your model.

What’s the one thing you’d want

your EMR vendor to do more of

around APIs?

Yes

Absolutely

God,

please yes

Yes, this is

our

strategy

For sure

Can open APIs and an app-based ecosystem

accelerate your organization's response to

changing market dynamics?

Press EHR vendors – “Coalition of the willing”

Upgrade your EHR and integration technology platforms to versions that support FHIR

Begin API governance discussions

Concentrate on EHR UX issues before functional enhancements

Plan your first FHIR projects based on vendor and staff readiness

Encourage your integration and technology teams to experiment with the technologies

underlying FHIR, including JSON and RESTful APIs

Educate key interface and application development staff on FHIR essentials

Provider action items

Q&A and Contact Information

Santosh Mohan, MMCi FHIMSS

Member

HIMSS Innovation Committee

Twitter: @santoshSmohan

LinkedIn.com/in/santoshmohan

santosh.mohan@fuqua.duke.edu

Rasu B. Shrestha, MD MBA

Chief Strategy Officer

Atrium Health

Twitter: @RasuShrestha

LinkedIn.com/in/rasushrestha

rasu.shrestha@gmail.com

Grahame Grieve

FHIR Product Director

HL7 International

Twitter: @GrahameGrieve

LinkedIn.com/in/grahame-grieve-952637

grahame@healthintersections.com.au